Infectious Diseases and Mass Gatherings

Evidence for transmission of SARS-CoV-2 at religious mass gatherings: A systematic review

Background

Transmission of SARS-CoV-2 at major mass gatherings (MGs) has been observed during the COVID-19 pandemic.

Methods

In this systematic review done according to the PRISMA guidelines, PubMed and Scopus databases were searched for relevant studies to describe the epidemiology of SARS-CoV-2 in relation to major religious MGs including the Grand Magal of Touba (GMT), Hajj, Umrah, Kumbh Mela, Arbaeen and Lourdes pilgrimage during the COVID-19 pandemic.

Results

Ten articles met the inclusion criteria and were included.No cases of SARS-CoV-2 were detected at 2020 and 2021 GMT or at the 2020 Hajj. In a small study, 7 % of tested individuals were positive after the 2022 GMT. SARS-CoV-2 prevalence during the 2021-2022 Hajj and Umrah seasons varied from 0 to 15 % in different studies. At the 2021 Kumbh Mela, 0.4 million COVID-19 cases were diagnosed among returning pilgrims across India and 1 % tested positive during a one-day survey conducted on participants. During the 2021 Arbaeen pilgrimage, 3 % pilgrims were tested positive. No relevant data were found in relation to SARS-CoV-2 transmission at the 2021 Arbaeen and Lourdes pilgrimages.

Conclusion

The transmission of the SARS-CoV-2 virus during religious MG events depends on many factors such as: the number and density of pilgrims, the intensity of circulation of the virus in the hosting country and in countries sending international participants at the time of the event, the transmissibility of virus variants at the time of the event, the various preventive measures adopted, and the immune status of the pilgrims.

Epidemiology of bacterial resistance at the Grand Magal of Touba in Senegal

BACKGROUND

The Grand Magal of Touba (GMT) associates with risks of infection, but no study on the circulation of resistant bacteria has yet been conducted.

MATERIALS AND METHODS

qPCR was performed on rectal samples from GMT pilgrims between 2018 and 2021, before and after their participation in the gathering. Rectal samples from between 2018 and 2020 were also cultured on specific media, and antibiotic susceptibility testing was performed.

RESULTS

Forty-one of the 296 (13.8%) pilgrims had at least one gastrointestinal symptom and 91/290 (31.4%) acquired pathogenic bacteria, mostly Escherichia coli. A total of 54.7% of pilgrims reported washing their hands more frequently than usual and 89.2% used soap. One hundred and five (36.2%) acquired at least one resistance gene, notably CTX-M A (21.0%), SHV (16.5%) and TEM (8.2%). The strains isolated by culture were mostly E. coli. These bacteria were found to be sensitive to carbapenems and resistant to amoxicillin and amoxicillin-clavulanic acid. The acquisition of enteroaggregative E. coli was independently associated with CTX-M A and TEM acquisition.

CONCLUSION

Pilgrims presented a risk for acquisition of CTX-M A after the GMT. Surveillance of the prevalence of resistant bacteria and the occurrence of associated clinical infections among pilgrims are necessary in the future.

Respiratory viral infections during Hajj seasons

Respiratory viral infections pose a public health concern during mass gathering (MG) events. Sustainable and continuous surveillance of respiratory viruses remains a priority to early identify and prevent potential outbreaks. This article reviews recent literature addressed the prevalence and diversity of circulating respiratory viruses during Hajj pilgrimage, one of the largest planned religious MG events held annually in Saudi Arabia. The variation between studies with respect to study design, sample size, time of sample collection (pre-, during, and pos-Hajj), type of participants (e.g., symptomatic vs. a symptomatic pilgrims), and laboratory procedure was highlighted. The majority of these studies were conducted on the 2019 Hajj season or earlier, prior to the emergence of COVID-19 which had significant impact on the past three Hajj seasons (2020, 2021, and 2022). A summary about key aspects related to organization of Hajj during COVID-19 pandemic and the implementation of exceptional infection control strategies is provided.

Healthcare policies, precautionary measures and outcomes of mass gathering events in the era of COVID-19 pandemic: Expedited review

With the onset of the COVID-19 pandemic in early 2020, several countries suspended or restricted mass gathering (MG) events to mitigate the risk of superspreading events. Prohibiting MGs aimed to lessen the likelihood of highly infectious persons coming into close contact with many others. Now that the world has opened its doors wide and removed most of precautionary measures, many questions arise. In this review, we aimed to summarize the current evidence regarding the policies and regulations that were implemented for the safe return of MG events. Besides, we highlighted the impact of the return of MG events during 2021 on the trajectory of COVID-19 spread. Canceling MG events can carry religious, societal, economic, and public negative consequences necessitating the safe return of these events. The experience with the COVID-19 pandemic was the foundation for the recommendations for the safe conduction of MG events during the pandemic by international public health bodies. When policymakers adequately applied precautionary measures and strategic approaches, we witnessed the safe holding of huge MG events without aggravating the COVID-19 situation or increasing the number of new cases beyond the capacity and readiness of the national healthcare system.

Hand Hygiene Knowledge and Practices Among Visitors to the Holy Masjid (Masjid Al-Haram) During the Month of Ramadan in 2023

Introduction Visits to the Holy Masjid are considered mass gatherings (MGs), defined as concentrations of people at a specific location for a certain objective over a predetermined amount of time. Such gatherings might strain the host nation's preparation and reaction capabilities, increasing the chances of spreading infectious diseases. Aim To evaluate the comprehension of hand hygiene (HH) and proper HH habits among visitors to the Holy Masjid during the month of Ramadan in 2023. Methods A total of 690 visitors to the Holy Masjid were interviewed for this cross-sectional study. The questionnaire was developed using model questions from another published survey. Results Of the participants, 541 (78.4%), predominantly female, had generally good knowledge about HH. A total of 282 (40.9%) participants used nothing to clean their hands after shaking hands with someone. Four hundred and eighty (69.6%) participants were aware that poor HH does not spread HIV/AIDS, and 504 (73%) stated that consistent HH does not reduce the body's natural immunity. A total of 530 (76.8%) participants with good knowledge about HH cleaned their hands before meals, compared to 131 (19%) participants with poor knowledge of HH. Conclusion Based on the results of our study, the participants' awareness of HH was generally high, with most recognizing the role of good HH in preventing common infectious diseases, such as gastrointestinal and respiratory infections. However, certain aspects of HH, such as the necessity and proper use of alcohol-based hand sanitizers, were not well understood. Regular, focused awareness-raising initiatives are recommended to enhance HH knowledge and practices among visitors to the Holy Masjid.

Community pharmacists' knowledge, prospective and practice towards health related illness at Hajj and Umrah: A cross sectional study

Objectives

To assess the community pharmacists' (CPs) knowledge, attitude, and perception of health-related illness among pilgrims, and to investigate the common diseases and the pattern of medications dispensed by CPs during Hajj and Umrah seasons.

Method

A cross-sectional study was carried out in Riyadh, Saudi Arabia over two months in 2022, through electronic platform using prevalidated questionnaires adopted from the literature. The questionnaires were divided into 4 sections assessing the CP's knowledge, attitude, and perception about health-related illness, common dispensed agents, and required vaccination during Hajj and Umrah.

Results

A total of 544 CPs, mostly between the age of 31-40 (69.9%), participated in this research. About 87.9% of the CPs received a pilgrim after performing their rituals coming to the pharmacy complaining of infection or health problem. In this study, 99.8%(n = 544), 99.6%(n = 543), and 92.7% (n = 505) of the CPs identified influenza, food poisoning, and diarrhea/gastroenteritis as the most common issues during the Hajj & Umrah season respectively. As results, anti-diarrheal agents (96.3%), painkillers (87.3%), inhalers (89.4%), and sunscreens (88.3%) were the most requested pharmaceutical agents. Additionally, 96.7%(n = 527) of the CPs agreed that vaccination is safe to be given to Hajj and Umrah pilgrims particularly for those aged ≥ 65 years, and 89.4%(n = 487) of them reported awareness of vaccines that are required by Saudi Ministry of Health. Both Influenza and meningococcal meningitis vaccines were identified by 99.8% of the CPs, but polio vaccine was identified by 33.9%.

Conclusion

Community pharmacists provided pharmaceutical care services for Hajj and Umrah pilgrims. The majority of CPs had adequate knowledge about viral diseases during Hajj and Umrah and their requirement for vaccination.

Threat of Antimicrobial Resistance among Pilgrims with Infectious Diseases during Hajj: Lessons Learnt from COVID-19 Pandemic

Hajj pilgrimage is a large mass gathering global event that may facilitate the spread and emergence of various infectious diseases as well as antimicrobial resistance (AMR) in a local and global scenario. Planning and preparing for these public health issues is a challenging and complex process for the Kingdom of Saudi Arabia (KSA) health authorities. Despite multiple efforts for the prevention and treatment of infectious diseases through longtime funding in education and medical care, the prevalence of infectious disease is still high among Hajj pilgrims. The commonly observed infectious diseases during Hajj include respiratory tract infections (influenza and pneumonia), urinary tract infections and skin infections that may necessitate the use of antimicrobials. Beta-lactams are used as a first-line treatment for hospital acquired infections as well as community acquired infections due to their broad-spectrum activity. However, most of the bacterial isolates such as Staphylococcus spp., Pseudomonas spp. and E. coli are resistant to beta-lactams. Irrational use of antimicrobials, lack of infection prevention practices and suboptimal healthcare access further exacerbate the risk of spreading AMR among Hajj pilgrims. Enhanced collaboration between countries, sharing of best practices and international cooperation are crucial in addressing AMR threats among pilgrims. Consequently, robust surveillance systems for early detection and monitoring of AMR, collaboration with national as well as international healthcare agencies, effective infection prevention and control measures, public awareness and rational use of antimicrobials via antimicrobial stewardship programs are required to mitigate the risk of AMR and ensure the health and well-being of pilgrims during Hajj.

Moderately Low Effectiveness of the Influenza Quadrivalent Vaccine: Potential Mismatch between Circulating Strains and Vaccine Strains

The annual seasonal influenza vaccination is the most effective way of preventing influenza illness and hospitalization. However, the effectiveness of influenza vaccines has always been controversial. Therefore, we investigated the ability of the quadrivalent influenza vaccine to induce effective protection. Here we report strain-specific influenza vaccine effectiveness (VE) against laboratory-confirmed influenza cases during the 2019/2020 season, characterized by the co-circulation of four different influenza strains. During 2019-2020, 778 influenza-like illness (ILI) samples were collected from 302 (39%) vaccinated ILI patients and 476 (61%) unvaccinated ILI patients in Riyadh, Saudi Arabia. VE was found to be 28% and 22% for influenza A and B, respectively. VE for preventing A(H3N2) and A(H1N1)pdm09 illness was 37.4% (95% CI: 43.7-54.3) and 39.2% (95% CI: 21.1-28.9), respectively. The VE for preventing influenza B Victoria lineage illness was 71.7% (95% CI: -0.9-3), while the VE for the Yamagata lineage could not be estimated due to the limited number of positive cases. The overall vaccine effectiveness was moderately low at 39.7%. Phylogenetic analysis revealed that most of the Flu A genotypes in our dataset clustered together, indicating their close genetic relatedness. In the post-COVID-19 pandemic, flu B-positive cases have reached three-quarters of the total number of influenza-positive cases, indicating a nationwide flu B surge. The reasons for this phenomenon, if related to the quadrivalent flu VE, need to be explored. Annual monitoring and genetic characterization of circulating influenza viruses are important to support Influenza surveillance systems and to improve influenza vaccine effectiveness.

Undiagnosed and missed active pulmonary tuberculosis during mass gatherings: a prospective cross-sectional study from the Hajj pilgrimage

Mass gatherings increase the risk of infectious diseases transmission including tuberculosis (TB). The Hajj pilgrimage to Mecca, Saudi Arabia, is attended by over 2 million pilgrims many of whom are from high TB-burden countries, and has been linked to increased risk of TB acquisition among travellers. We investigated the burden of undiagnosed and missed active pulmonary TB (PTB) among Hajj pilgrims symptomatic for cough. The study was conducted among hospitalised and non-hospitalised travellers attending the Hajj pilgrimage in 2016 and 2017. Questionnaires were used to collect relevant data and sputum samples were collected from participants and processed using the Xpert MTB-RIF assay. Non-hospitalised pilgrims (n = 1510) originating from 16 high and medium TB-burden countries were enrolled. Undiagnosed, rifampicin-sensitive, active PTB was identified in 0.7%. Comorbidities (adjOR = 5.9 [95% CI = 1.2-27.8]), close contact with a TB case (adjOR = 5.9 [95% CI = 1.2-27.8]), cough in household (adjOR = 4.46 [95% CI = 1.1-19.5]), and previous TB treatment (adjOR = 10.1 [95% CI = 4.1-98.1]) were independent risk factors for TB. Of the hospitalised pilgrims (n = 304), 2.9% were positive for PTB, and 2.3% were missed, including a rifampicin-resistant case. History of TB treatment was associated with increased risk of TB (adjOR = 8.1 [95% CI = 1.3-48.7]). International mass gatherings may play an important role in the global epidemiology of TB. Preventive measures should be directed to reducing the risk of TB importation and transmission during Hajj and other similar events.

Risk factors for heat-related illnesses during the Hajj mass gathering: an expert review

Human exposure to a hot environment may result in various heat-related illnesses (HRIs), which range in severity from mild and moderate forms to life-threatening heatstroke. The Hajj is one of the largest annual mass gatherings globally and has historically been associated with HRIs. Hajj attracts over two million Muslim pilgrims from more than 180 countries to the holy city of Makkah, Kingdom of Saudi Arabia. Several modifiable and non-modifiable factors render Hajj pilgrims at increased risk of developing HRIs during Hajj. These include characteristics of the Hajj, its location, population, and rituals, as well as pilgrims' knowledge of HRIs and their attitude and behavior. Makkah is characterized by a hot desert climate and fluctuating levels of relative humidity. Pilgrims are very diverse ethnically and geographically, with different adaptations to heat. Significant proportions of the Hajj population are elderly, obese, and with low levels of fitness. In addition, many have underlying health conditions and are on multiple medications that can interfere with thermoregulation. Other factors are inherent in the Hajj and its activities, including crowding, physically demanding outdoor rituals, and a high frequency of infection and febrile illness. Pilgrims generally lack awareness of HRIs, and their uptake of preventive measures is variable. In addition, many engage in hazardous behaviors that increase their risk of HRIs. These include performing rituals during the peak sunshine hours with no sun protection and with suboptimal sleep, nutrition, and hydration, while neglecting treatment for their chronic conditions. HRIs preventive plans for Hajj should incorporate measures to address the aforementioned factors to reduce the burden of these illnesses in future Hajj seasons. Lessons from the Hajj can be used to inform policy making and HRIs preventive measures in the general population worldwide.

The impact of mass gatherings on the local transmission of COVID-19 and the implications for social distancing policies: Evidence from Hong Kong

Mass gatherings provide conditions for the transmission of infectious diseases and pose complex challenges to public health. Faced with the COVID-19 pandemic, governments and health experts called for suspension of gatherings in order to reduce social contact via which virus is transmitted. However, few studies have investigated the contribution of mass gatherings to COVID-19 transmission in local communities. In Hong Kong, the coincidence of the relaxation of group gathering restrictions with demonstrations against the National Security Law in mid-2020 raised concerns about the safety of mass gatherings under the pandemic. Therefore, this study examines the impacts of mass gatherings on the local transmission of COVID-19 and evaluates the importance of social distancing policies. With an aggregated dataset of epidemiological, city-level meteorological and socioeconomic data, a Synthetic Control Method (SCM) is used for constructing a 'synthetic Hong Kong' from over 200 Chinese cities. This counterfactual control unit is used to simulate COVID-19 infection patterns (i.e., the number of total cases and daily new cases) in the absence of mass gatherings. Comparing the hypothetical trends and the actual ones, our results indicate that the infection rate observed in Hong Kong is substantially higher than that in the counterfactual control unit (2.63% vs. 0.07%). As estimated, mass gatherings increased the number of new infections by 62 cases (or 87.58% of total new cases) over the 10-day period and by 737 cases (or 97.23%) over the 30-day period. These findings suggest the necessity of tightening social distancing policies, especially the prohibition on group gathering regulation (POGGR), to prevent and control COVID-19 outbreaks.

Impact of a Health Education Intervention on the Incidence of Influenza-Like Illnesses (ILI) During Hajj via Smartphone Application

This study was aimed at demonstrating the impact of a health education intervention on reducing the incidence of influenza-like illnesses symptoms among Malaysian Hajj pilgrims. This study utilizes a quasi-experimental study in the evaluation of the impact of the intervention. Participants were recruited during Hajj orientation courses organized by private Hajj companies. Participants from two companies were assigned to an intervention group and control group, respectively. The intervention group received a smartphone-based health education intervention guided by the Health Belief Model (HBM), while the control group received a regular Hajj guide intervention smartphone application before departure to Hajj. Data on the incidence of influenza-like illnesses (ILI) were collected from participants from two Hajj companies before and after returning from Hajj. Data analysis was conducted using SPSS with descriptive analysis, and analytical tests were conducted at 5% significance level. A total of 102 pilgrims completed the study in both intervention and control groups. The incidence of ILI and Non-ILI symptoms were statistically significant when the intervention and control groups (p = 0.049) were compared. In conclusion, health education has an impact on reducing the incidence of ILI and non-ILI among Hajj pilgrims.

A scoping review of the risk factors and strategies followed for the prevention of COVID-19 and other infectious diseases during sports mass gatherings: Recommendations for future FIFA World Cups

Objective

Sports mass gatherings of people pose particular concerns and place an additional burden on the host countries and the countries of origin of the travelers. It is imperative to identify how countries dealt with various communicable diseases in the context of previous world cups and identify possible advice for protection from outbreaks.

Methods

A scoping review was employed in this study and a PRISMA extension for scoping reviews was employed to guide the reporting of this study. A systematic search was performed using PubMed, Embase, Web of Science, SCOPUS, SportDiscus, and Google scholar. The search strategy included two main strings viz "communicable disease" AND "sport" AND "setting" as keywords for each string. A total of 34 studies were included in this review.

Results

Information on risk factors for infectious diseases during FIFA, and recommendations for disease prevention in various stages of the event: pre-event, during, and post-event were charted. These strategies can be achieved with the empowerment of the public by enhancing their social responsibility and the coordination between the healthcare system, the ministry of public health, and other stakeholders.

Conclusion

The findings will support planning for protection strategies to prevent any outbreak while having the FIFA World Cup or any other sports gatherings. A model was constructed to present the findings and recommendations from this review.

Respiratory pathogens among ill pilgrims and the potential benefit of using point-of-care rapid molecular diagnostic tools during the Hajj

We investigated respiratory pathogens among ill Hajj pilgrims from Marseille. We also discuss the potential role of point-of-care (POC) rapid molecular diagnostic tools for this purpose. Clinical data were collected using a standardised questionnaire. Influenza A and B viruses, human rhinovirus and human coronaviruses, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Klebsiella pneumoniae were investigated using real-time PCR in respiratory samples obtained during travel, at the onset of symptoms. 207 participants were included. A cough, expectoration, rhinitis and a sore throat were the most frequent respiratory symptoms, followed by loss of voice and dyspnoea. 38.7% and 25.1% of pilgrims reported a fever and influenza-like symptoms, respectively. 59.4% pilgrims received antibiotics. Rhinovirus (40.6%) was the most frequent pathogen, followed by S. aureus (35.8%) and H. influenzae (30.4%). Virus and bacteria co-infections were identified in 28.5% of participants. 25.1% pilgrims who were positive for respiratory bacteria did not receive antibiotic treatment. In the context of the Hajj pilgrimage, it is important to detect infections that can be easily managed with appropriate treatment, and those that can affect prognosis, requiring hospitalisation. POC rapid molecular diagnostic tools could be used for patient management at small Hajj medical missions and to rationalise antibiotic consumption among Hajj pilgrims.

Assessment of Community Behavior and COVID-19 Transmission during Festivities in India: A Qualitative Synthesis through a Media Scanning Technique

In India during the first wave of COVID-19 infection, the authorities were concerned about the advent of the festive season, which could lead to a surge in cases of SARS-CoV-2 infection. The present study attempted to assess the socio-behavioral aspects of COVID-appropriate behavior (CAB) at individual and community levels, and their impact on the transmission of COVID-19 during festivities in India. Media scanning was conducted to qualitatively assess CAB by analyzing 284 news reports from across India; quantitative data on COVID-19 daily cases from March 2020 to December 2020 were used to determine the trends of the adjusted test positivity (ATP) ratio for six cities. Peaks in ATP were observed in Chandigarh, Delhi-NCR in North India during and after Dussehra and Deepavali, and in Mumbai, in the west, after Navratri. Additionally, a surge in ATP was observed in Trivandrum after Onam and in Chennai around Deepavali in the south; meanwhile, in the eastern city of Kolkata, cases increased following Durga Puja. The major challenges were adherence to CAB viz. social distancing, hygiene, and compliance with the mask mandate. Microlevel CAB indicated relatively higher laxity in maintaining hand hygiene in all cities. Observations from the current study indicate that innovative community-driven initiatives during festivals in each geographical zone are key to the large-scale implementation of disease prevention measures.

Mass gathering events and the spread of infectious diseases: Evidence from the early growth phase of COVID-19

This paper studies the impact on reported coronavirus 2019 (COVID-19) cases and deaths in Spain resulting from large mass gatherings that occurred from March 6 to March 8, 2020. To study these outcomes, the geographic differences in the planned pre-pandemic major events that took place on these dates were exploited, which is a quasi-random source of variation for identification purposes. We collected daily and detailed information about the number of attendees at football (soccer) and basketball matches in addition to individuals participating in the Women's Day marches across Spain, which we merged with daily data on reported COVID-19 cases and deaths at the provincial level. Our results reveal evidence of non-negligible COVID-19 cases related to the differences in the percentage of attendees at these major events from March 6 to March 8. In a typical province, approximately 31% of the average daily reported COVID-19 cases per 100,000 inhabitants between mid-March and early April 2020 can be explained by the participation rate in those major events. A back-of-the-envelope calculation suggests that this implies almost five million euros (169,000 euros/day) of additional economic cost in the health system of a typical province with one million inhabitants in the period under consideration. Several mechanisms behind the spread of COVID-19 are also examined.

Assessment of supplied water quality during mass gatherings in arid environments

Mass gathering events commonly encounter environmental challenges that necessitate assurance of water quality and food security. The current outbreak of the coronavirus disease 2019 (COVID-19) call for maintaining safe drinking water supply and providing assessment tools of drinking water quality to avoid contamination in water sources or distribution networks. Arid environmental conditions also add more stress on supplied water to mass gathering events. Herein, we assess the quality of the water supply (desalinated 95% and groundwater 5%) in Makkah city, Saudi Arabia during a mass gathering event in 2019 (9.6 million people) for religious purposes. Fifty five samples were randomly collected from nine different districts of Makkah city, analyzed for TDS, turbidity, pH, EC, free Cl₂, Al, Cd, Pb, Cr, F, major ions, coliform and E.coli bacteria and were finally used to estimate the water quality index (WQI). Major ions, trace elements and heavy metals analyses show values below permissible limits in most of the samples, while a few samples show slightly higher values. No bacterial count found in any sample. WQI values of all fifty-five samples were below 50 and were identified as “excellent water”. The WQI variations could be attributed to the distribution network conditions rather than a direct impact of adding groundwater with uncontrolled chemical composition. The use of WQI to report the quality of water during mass gathering events to governmental authorities has been proved to be beneficial and should be applied for further mass gathering events worldwide.

Meningococcal Disease and Immunization Activities in Hajj and Umrah Pilgrimage: a review

Invasive meningococcal disease (IMD) outbreaks associated with Hajj and Umrah pilgrimage events in the Kingdom of Saudi Arabia (KSA) are well recognized. Past outbreaks have been associated with substantial intercontinental spread of specific Neisseria meningitidis serogroups. The emergence of meningococcal serogroup W (MenW) was a global concern following the 2000/2001 Hajj outbreaks. Broader compulsory meningococcal serogroups A, C, W and Y (MenACWY) immunization strategies for pilgrims were introduced in response to these events and led to substantial declines in IMD cases associated with these mass gatherings. However, there remains potential for future outbreaks either within KSA during the Hajj or in local populations via pilgrim meningococcal transmission on their return. While the annual Hajj involves pilgrims from over 185 countries, two-thirds of these arrive from 13 countries, chiefly from across South-East Asia, the Middle East and North African (MENA) regions; for which we review the relevant epidemiology of IMD and meningococcal carriage. While disease surveillance is limited and data are often lacking, MenB is an important serogroup associated with IMD and carriage in a number of countries. Available literature suggests that most pilgrims receive polysaccharide MenACWY vaccines (which do not impact carriage and onward transmission) and incomplete compliance with visa/entry immunization regulations is reported. Existing preventative approaches for visiting pilgrims require continued oversight. More complete compliance and switching to the conjugated MenACWY vaccine can provide more robust and broader protection for pilgrims. Additional immunization options could also be considered.

Impact of COVID-19 Social Distancing Mandates on Gastrointestinal Pathogen Positivity: Secondary Data Analysis

Background

Acute gastrointestinal (GI) illnesses are of the most common problems evaluated by physicians and some of the most preventable. There is evidence of GI pathogen transmission when people are in close contact. The COVID-19 pandemic led to the sudden implementation of widespread social distancing measures in the United States. There is strong evidence that social distancing measures impact the spread of SARS-CoV-2, and a growing body of research indicates that these measures also decrease the transmission of other respiratory pathogens.

Objective

This study aims to investigate the impact of COVID-19 social distancing mandates on the GI pathogen positivity rates.

Methods

Deidentified GI Panel polymerase chain reaction test results from a routinely collected diagnostic database from January 1, 2019, through August 31, 2020, were analyzed for the GI pathogen positivity percentage. An interrupted time series analysis was performed, using social distancing mandate issue dates as the intervention date. The following 3 target organisms were chosen for the final analysis to represent different primary transmission routes: adenovirus F40 and 41, norovirus GI and GII, and Escherichia coli O157.

Results

In total, 84,223 test results from 9 states were included in the final data set. With the exception of E coli O157 in Kansas, Michigan, and Nebraska, we observed an immediate decrease in positivity percentage during the week of social distancing mandates for all other targets and states. Norovirus GI and GII showed the most notable drop in positivity, whereas E coli O157 appeared to be least impacted by social distancing mandates. Although we acknowledge the analysis has a multiple testing problem, the majority of our significant results showed significance even below the .01 level.

Conclusions

This study aimed to investigate the impact of social distancing mandates for COVID-19 on GI pathogen positivity, and we discovered that social distancing measures in fact decreased GI pathogen positivity initially. The use of similar measures may prove useful in GI pathogen outbreaks. The use of a unique diagnostic database in this study exhibits the potential for its use as a public health surveillance tool.

The role of non-pharmaceutical interventions on influenza circulation during the COVID-19 pandemic in nine tropical Asian countries

BACKGROUND

Low global influenza circulation was reported during the coronavirus-19 pandemic. We explored relationships between non-pharmaceutical interventions (NPIs) and influenza in tropical Asian countries.

METHODS

Using World Health Organization (WHO) surveillance data from 2015 to 2019 and the WHO shiny app, we constructed expected seasonal influenza epidemic curves from March 2020 to June 2021 and compared the timing, and average percent positivity with observed data. We used multivariate regression to test associations between ordinal NPI data (from the Oxford Stringency Index) 4 weeks before the expected 2020/21 epidemics and present adjusted incidence rate ratio (IRR) or relative proportion ratio (RPR) and 95% confidence intervals (CI).

RESULTS

Data from nine countries predicted 18 seasonal epidemics; seven were observed. Five started 6-24 weeks later, and all were 4-21 weeks shorter than expected. Five epidemics had lower maximum peak values (percent positivity), and all but one had lower average percent positivity than expected. All countries implemented NPIs. Each increased level of school closure reduced risk of an epidemic by 43% (IRR = 0.57, CI: 0.34, 0.95). Each increased level of canceling public events reduced the average percent positivity across the season by 44% (RPR = 0.56, CI: 0.39, 0.82) and each increased level in restricting internal movements reduced it by 41% (RPR = 0.59, CI: 0.36, 0.96). Other NPIs were not associated with changes.

CONCLUSIONS

Among nine countries, the 2020/21 seasonal epidemics were delayed, shorter, and less intense than expected. Although layered NPIs were difficult to tease apart, school closings, canceling public events, and restricting internal movements before influenza circulation seemed to reduce transmission.

Evaluation of the rate, pattern and appropriateness of antibiotic prescription in a cohort of pilgrims suffering from upper respiratory tract infection during the 2018 Hajj season

Hajj is associated with an increased risk of the transmission of infectious diseases including upper respiratory tract infections (URTIs). It can be a focal point for the emergence, persistence and dissemination of antimicrobial-resistant (AMR) bacteria. The overuse of antibiotics during Hajj can promote the development of antimicrobial resistance. Little information is known regarding the true appropriateness of prescribing antibiotics for treating URTIs during Hajj. Here we studied the rate, patterns and appropriateness of antibiotic prescription among a cohort of pilgrims who were treated for URTIs during the 2018 Hajj season. Adult pilgrims who sought medical services for URTIs [presenting with coryza, runny nose, nasal irritation, nasal congestion, cough, sore throat, headache or fever (even if subjective)] within the Holy sites were enrolled in this study and consented to provide swabs and medical information. A total of 121 pilgrims were enrolled, with the majority (60.3 %) originating from North African Arab countries. Most were male (89.3 %) with a median age of 45 years. Bacterial infections were detected in 7.3 % (n=9) of the URTI cases. The identified bacteria included Haemophilus influenzae (n=6, all resistant to ampicillin), Streptococcus pneumoniae (n=2), Staphylococcus aureus (n=1, resistant to oxacillin) and Moraxella catarrhalis (n=1, resistant to ampicillin and trimethoprim/sulfamethoxazole). The antibiotic prescription rate was 52.1%, most of which was amoxicillin (81 %). The data demonstrated that the proportion of appropriate practices in treating bacterial URTIs in this cohort was 45.5 %. This study highlights the need for implementing laboratory identification of the aetiological agents and related AMR profiles when treating URTIs in Hajj, rather than relying on clinical assessment alone.

Pattern of utilization, disease presentation, and medication prescribing and dispensing at 51 primary healthcare centers during the Hajj mass gathering

Background

The majority of pilgrims seeking healthcare during Hajj are seen at primary healthcare centers (PHCCs). Data on the utilization of these facilities during Hajj can aid in directing optimal health services delivery and allocation of resources during the pilgrimage.

Method

We investigated the pattern of disease presentation, caseload, and medication prescribing and dispensing at 51 PHCCs during the 2019 Hajj. Data on patients’ demographics, diagnoses, and prescribed medications were retrieved from each PHCC’s electronic records and analyzed. Data were also used to calculate six of the World Health Organization (WHO) indicators for drug use at these facilities.

Results

Data were captured for 99,367 patients who were mostly Hajj pilgrims (95.4%), male (69.1%) from the Eastern Mediterranean (60.8%) and had a mean age of 46.6 years (SD = 14.9). Most patients (85.2%) were seen in Mina and towards the end of Hajj. The majority of patients (96.0%) had a single diagnosis; most commonly, respiratory (45.0%), musculoskeletal (17.2%), and skin (10.5%) diseases. Patients were prescribed 223,964 medications, mostly analgesics (25.1%), antibacterials for systemic use (16.5%), anti-inflammatory and antirheumatic products (16.4%), and cough and cold preparations (11.9%). On average, 2.25 (SD = 0.94) medications were prescribed per consultation, with low (1.3%) prevalence of polypharmacy. An antibiotic and an injectable were prescribed in 43.6 and 2.67% of patient encounters, respectively. Most (92.7%) of the prescribed drugs were actually dispensed, in an average time of 8.06 min (SD = 41.4). All PHCCs had a copy of the essential drugs list available, on which all the prescribed drugs appeared.

Conclusion

Respiratory illnesses are the main reason for PHCCs visits during Hajj, and analgesics and antibiotics are the most common medications prescribed to pilgrims. Our results, including the calculated WHO drug use indicators, contribute to evidence-based optimization of primary healthcare services during Hajj.

What's new in travellers' diarrhoea: updates on epidemiology, diagnostics, treatment and long-term consequences

BACKGROUND

Travellers' diarrhoea (TD) is the most common clinical syndrome affecting travellers. This narrative review summarizes key discoveries reported in the last two years related to TD and suggests areas for future research.

METHODS

A PubMed literature search was conducted for novel data in TD research published between 12 January 2018 and 12 January 2020. Inclusion was based on contribution to epidemiology, aetiology, diagnostics, management and long-term consequences and relevance to public health, discovery and clinical practice.

RESULTS

The initial literature search yielded 118 articles. We retrieved 72 and reviewed 31 articles for inclusion. The findings support our understanding that TD incidence varies by traveller group and environment with students and military-travel remaining moderately high risk, and control of food and water in mass gathering events remain an important goal. The growth of culture-independent testing has led to a continued detection of previously known pathogens, but also an increased detection frequency of norovirus. Another consequence is the increase in multi-pathogen infections, which require consideration of clinical, epidemiological and diagnostic data. Fluoroquinolone resistant rates continue to rise. New data on non-absorbable antibiotics continue to emerge, offering a potential alternative to current recommendations (azithromycin and fluoroquinolones), but are not recommended for febrile diarrhoea or dysentery or regions/itineraries where invasive pathogens are likely to cause illness. Recent studies investigated the interaction of the microbiome in TD prevention and consequences, and while discriminating features were identified, much uncertainty remains. The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and carriage is increasing. Finally, continued research documents the post-infectious consequences, whereas mechanisms of reactive arthritis and post-infectious IBS necessitate further investigation.

CONCLUSIONS

Globally, TD remains an important travel health issue and advances in our understanding continue. More research is needed to mitigate risk factors where possible and develop risk-based management strategies to reduce antibiotic usage and its attendant consequences.

Agent-Based Simulation Framework for Epidemic Forecasting during Hajj Seasons in Saudi Arabia

The religious pilgrimage of Hajj is one of the largest annual gatherings in the world. Every year approximately three million pilgrims travel from all over the world to perform Hajj in Mecca in Saudi Arabia. The high population density of pilgrims in confined settings throughout the Hajj rituals can facilitate infectious disease transmission among the pilgrims and their contacts. Infected pilgrims may enter Mecca without being detected and potentially transmit the disease to other pilgrims. Upon returning home, infected international pilgrims may introduce the disease into their home countries, causing a further spread of the disease. Computational modeling and simulation of social mixing and disease transmission between pilgrims can enhance the prevention of potential epidemics. Computational epidemic models can help public health authorities predict the risk of disease outbreaks and implement necessary intervention measures before or during the Hajj season. In this study, we proposed a conceptual agent-based simulation framework that integrates agent-based modeling to simulate disease transmission during the Hajj season from the arrival of the international pilgrims to their departure. The epidemic forecasting system provides a simulation of the phases and rituals of Hajj following their actual sequence to capture and assess the impact of each stage in the Hajj on the disease dynamics. The proposed framework can also be used to evaluate the effectiveness of the different public health interventions that can be implemented during the Hajj, including size restriction and screening at entry points.

Public health risks threatening health of people participating in mass gatherings: A qualitative study

Background

Mass gatherings (MGs) have made many problems for the health system and potentially threaten the health of those participated in these gatherings. MGs account for a range of public health risks including communicable diseases, waterborne diseases, water treatment, and outbreaks.

Objectives

The present study aimed to identify public health risks threatening the health of people participating in MGs in Iran.

Methods

A qualitative study was designed using a conventional qualitative content analysis approach. Participants were selected using a purposive sampling method among the managers and staff who have experiences in the field of health in MGs in Iran. Subjects were interviewed through individual in-depth interviews after obtaining informed consent. Semi-structured interviews were used to collect the data from December 2018 to February 2019. To analyze the data, the content of recorded interviews was written verbatim. Preliminary data were repeatedly and simultaneously retrieved to give a general understanding of them.

Results

The main theme emerged from data analysis on 16 interviews was related to public health risks involving the following categories: food hygiene deficiencies, communicable diseases risks, defects in health supervision, and the risk of environmental contamination.

Conclusion

It is of paramount importance to identify the risks threatening the health of people participating in MGs. In the present study, the main public health risks were detected.

Impact of non-pharmaceutical interventions against COVID-19 in Europe in 2020: a quasi-experimental non-equivalent group and time series design study

IntroductionThe current pandemic of coronavirus disease (COVID-19) is unparalleled in recent history as are the social distancing interventions that have led to a considerable halt on the economic and social life of so many countries.AimWe aimed to generate empirical evidence about which social distancing measures had the most impact in reducing case counts and mortality.MethodsWe report a quasi-experimental (observational) study of the impact of various interventions for control of the outbreak through 24 April 2020. Chronological data on case numbers and deaths were taken from the daily published figures by the European Centre for Disease Prevention and Control and dates of initiation of various control strategies from the Institute of Health Metrics and Evaluation website and published sources. Our complementary analyses were modelled in R using Bayesian generalised additive mixed models and in STATA using multilevel mixed-effects regression models.ResultsFrom both sets of modelling, we found that closure of education facilities, prohibiting mass gatherings and closure of some non-essential businesses were associated with reduced incidence whereas stay-at-home orders and closure of additional non-essential businesses was not associated with any independent additional impact.ConclusionsOur findings are that schools and some non-essential businesses operating 'as normal' as well as allowing mass gatherings were incompatible with suppressing disease spread. Closure of all businesses and stay at home orders are less likely to be required to keep disease incidence low. Our results help identify what were the most effective non-pharmaceutical interventions in this period.

Gastrointestinal symptoms and knowledge and practice of pilgrims regarding food and water safety during the 2019 Hajj mass gathering

BACKGROUND

Food and water-borne diseases (FWBDs) are a health risk at the Hajj mass gathering. The current study documented the prevalence and management of gastrointestinal (GI) symptoms among pilgrims during the 2019 Hajj and assessed their knowledge and practice concerning food and water safety.

METHOD

An analytical cross-sectional study was conducted in Macca, Saudi Arabia, among adult Hajj pilgrims from 28 countries. Data was collected from 15th-20th August 2019 by facer-to-face interviews using an anonymous structured questionnaire. Basic demographic data as well as information regarding pilgrims' knowledge and practice relating to food and water safety and any GI symptoms experienced during the Hajj was collected and analyzed.

RESULTS

The study enrolled 1363 pilgrims with a mean age of 50.1 years (SD = 12.3) and 63.4% (n = 845) were male. At least 9.7% (n = 133) of pilgrims experience GI symptoms and 5.1% (69/1363) suffered diarrhea. Most respondents drunk bottled water (99.4%, n = 1324) and obtained their food from their hotel /Hajj mission (> 86%). In general, pilgrims had good knowledge and practice in relation to food and water safety, although risky practices were noted concerning keeping food at unsafe temperatures and hazardous sharing of food and water. Gender, nationality and suffering GI symptoms during Hajj were significantly associated with good knowledge and good practice. There was a moderate but statistically significant positive correlation between knowledge and practice scores (rs = 0.41, p < 0.0001).

CONCLUSION

Despite overall good knowledge and self-reported practice, risky behaviors relating to food and water safety were identified among pilgrims, many of whom suffered from GI symptoms during Hajj. Our results can form the basis for developing tailored, targeted and effective interventions to improve pilgrims' knowledge and behavior and reduce the burden of FWBDs at the Hajj and beyond.

Respiratory infections among pilgrims at the Grand Magal of Touba: A comparative cohort controlled survey

BACKGROUND

The Grand Magal of Touba (GMT) is a large event gathering around 4-5 million participants every year. A pilot study conducted in 2017 among GMT pilgrims showed that 41.8% of participants reported respiratory symptoms, mostly due to rhinovirus (13.0%), coronaviruses (16.0%) and adenovirus (4.6%).

METHODS

A PCR-based prospective cohort study was conducted among GMT pilgrims and controls (who did not participate to the event) in two rural villages in South Senegal, in 2019.

RESULTS

93 pilgrims and 84 controls were included in the study. There were no significant differences between pilgrims and controls regarding demographic characteristics and chronic conditions. 60.2% of pilgrims reported respiratory symptoms during their stay in Touba, or soon after their return. By contrast, only 8.3% of controls reported respiratory symptoms after the GMT. The acquisition of rhinovirus, coronaviruses, Streptococcus pneumoniae and Moraxella catarrhalis was 22.6%, 6.5%, 17.2% and 6.8% respectively in pilgrims and was significantly higher than in controls (3.6%, 0%, 4.8% and 1.2% respectively). Respiratory symptoms post-GMT were five times more frequent in S. pneumoniae carriers (aOR = 5.18, 95%CI = [1.98-13.57]).

CONCLUSION

This study demonstrates that individuals who participated in the GMT were at higher risk of suffering from respiratory symptoms and that this was linked to the acquisition of S. pneumoniae.

An Aspect of Kumbh Mela Massive Gathering and COVID-19

Purpose of Review

Kumbh Mela, a religious gathering of Hindus held in India, is the largest massive gathering event in the world. The COVID-19 pandemic is an unprecedented healthcare crisis in recent times with effects reverberating in all spheres of human lives. India has registered the second highest number of COVID-19 cases. This paper aims to dwell in the religious and social background of Kumbh Mela massive gathering, as well as the ritualistic practices that could potentially entail public health risks in the current situation. It also aims to identify possible preparatory and interventional measures to evade such risks.

Recent Findings

In recent years, the increase in the number of people attending the Kumbh Mela has been phenomenal. Congregants are put up at the holy sites for several days. The sheer number of people assembling at the religious venues poses a great challenge to manage the crowds, to cater to the requirements of basic amenities, and to meet their healthcare needs. Some of the ritualistic practices could heighten the risk for transmission of respiratory pathogens. The COVID-19 pandemic has escalated over the past few months in India. The pandemic is expected to sustain its tempo in India throughout the foreseeable future. Organization of the forthcoming Kumbh Mela needs meticulous planning.

Summary

Kumbh Mela is a Hindu religious gathering at the banks of India’s rivers, held periodically. It witnesses assembly of huge numbers of people and has the potential to amplify the COVID-19 pandemic in India; this could overwhelm the healthcare system.

Health Risks, Preventive Behaviours and Respiratory Illnesses at the 2019 Arbaeen: Implications for COVID-19 and Other Pandemics

COVID-19 poses grave challenges for mass gatherings. One of the world’s largest annual gatherings, Arbaeen, occurs in Iraq. We studied respiratory symptoms and risk and protective factors using representative sampling of Arbaeen pilgrims in 2019 to inform prevention of COVID-19 transmission. Structured sampling was used to recruit walking pilgrims. A questionnaire asked about respiratory symptoms, risk, and preventive factors, including hygiene-related resources of toilet facilities. The commonest symptom reported by the 1842 participants (63.3% male, 36.7% female) was cough (25.6%). Eating in mawkibs (rest areas) with indoor kitchens and drinking only packaged water were associated with lower risk of cough (AOR = 0.72, CI = 0.56–0.94; AOR = 0.60; CI = 0.45–0.78, p < 0.05). Facemask use was associated with increased risk of cough (AOR = 2.71, CI = 2.08–3.53, p < 0.05). Handwashing was not protective against cough, or against (one or more of) cough, fever, or breathlessness in multivariate analysis. Toilet facilities often lacked running water (32.1%) and soap (26.1%), and had shared hand towels (17%). To reduce risk of respiratory infections including COVID-19 during Arbaeen or other mass gatherings, needs include running water, soap, and hygienic hand drying options or hand sanitiser. Education on proper handwashing and facemask approaches and monitoring around food preparation and eating spaces are needed.

Ethnicity is a major determinant of the pattern of dermatological diseases among pilgrims during the Hajj in 2019

The authors aim to explore the pattern and demographics of dermatological disorders occurring during Hajj 2019. Clinical records from three major public healthcare facilities in Al-Madinah Al-Munawara were retrieved for the period July-August, 2019. Collected data included age, gender, nationality, and dermatological complaints. 550 records were retrieved. Patients were 282 (51.3%) males and 268 (48.7%) females with a mean age of 58.3±12.6 years. Most patients were Asians (n=320, 58.2%), and Africans (n=183, 33.3%). Accidents (n=226, 41.1%), and infections (148, 26.9%) were the most common complaints. Asians and Africans had significantly: more accidents and less infections (P=0.002, P=0.027 respectively). They were the only category affected by exacerbations of auto immune diseases. Asian and African pilgrims are mainly affected by traumatic dermatologic conditions. Preventive awareness programs should target these ethnicities to reduce their higher rates of accidents. Other ethnicities need programs that promote hygienic practices and target infections.

Hand Hygiene Knowledge, Perception, and Practices among Domestic Visitors to the Prophet's Mosque in Al Madinah City Amid the COVID-19 Pandemic: A Cross-Sectional Study

This study aimed to assess hand hygiene knowledge, perception, and practices of visitors to the Prophet’s Mosque in Al Madinah City, Saudi Arabia. Using a self-administered electronic questionnaire, a cross-sectional survey was conducted among domestic residents, who visited the mosque between 31 July and 3 August 2020. Participants’ demographic data, hand hygiene knowledge, perception, and practices were collected. Four hundred participants aged 18–65 (median 36) years completed the survey, of which 215 (53.8%) were female. The visitors’ mean knowledge score about hand hygiene was 6.4 (± standard deviation (SD) 1.35) of total 12. Most participants (392, 98%) were aware of the role of hand hygiene in preventing Coronavirus Disease 2019 (COVID-19); nevertheless, 384 (96%) said hand hygiene lowers body immunity and 316 (79%) thought <60% alcohol is sufficient for hand disinfection. Males had a higher knowledge score than females (6.46 (±1.41) vs. 6.14 (±1.27), p = 0.02) and, visitors who had no formal education scored higher than those with post-graduate education (6.88 (±1.45) vs 5.73 (±1.12), p = 0.01). Washing hands with soap and water was the predominant method practiced after a meal (365, 91.7%), after toilet visit (354, 88.5%), after touching a surface (262, 65.7%), after waste disposal (332, 83.2%), and when hands were visibly dirty (357, 89.5%). Al Madinah visitors had moderate knowledge about hand hygiene, but demonstrated some knowledge gaps and negligence in practice that are crucial to curb the spread of COVID-19.

Health information, attitudes and actions at religious venues: Evidence from hajj pilgrims

Mass gatherings for sporting events, music shows, and religious needs continue to grow in our urban areas, requiring local authorities to develop safety procedures to mitigate the challenges of keeping the attendees safe. These challenges are even more pronounced at pilgrimage venues where social distancing and contact avoidance are difficult as pilgrims are required to perform various rituals in close proximity with others, in a sequential manner, either daily or weekly, as per their religious tenets. Over two million pilgrims attend the Hajj pilgrimage in Saudi Arabia annually. Keeping the local and visiting pilgrims safe from crowd crush, sunstroke, skin infections, recurrence of prior medical issues, and contagious diseases requires the Saudi government to allocate huge investments for health communication and prevention programs every year. However, there is no evidence to date that has empirically tested whether Hajj pilgrims' are able to receive such information and are subsequently adopting various health promoting behaviors. This study aims to do that by framing it within the Health Belief Model. Data collected and analyzed from 245 pilgrims in Makkah between September 9th-19th, 2017 suggests that roughly 48% of the pilgrims adopted all five protective measures. However, language barriers, limited health care facilities, and difficulties in purchasing prescription mediciens were cited as impediments to adopting healthy measures. The study concludes with recommendations for the KSA government agencies, Hajj authorities, Mission authorities and pilgrims, during various phases of travel-- i.e. pre-travel, during the pilgrimage and post-travel, in light of new emerging health threats.

Hajj and Umrah Mass Gatherings and COVID-19 Infection

Purpose of Review

We discuss the risk of COVID-19 in religious mass gathering events including Hajj and Umrah pilgrimages.

Recent Findings

The risk of transmission of respiratory viruses including COVID-19 is particularly high due to the overcrowding conditions at the Hajj and Umrah. The profile of the Hajj pilgrims who tend to be older and with multiple comorbidities corresponds to that of individuals at risk for severe COVID-19. In order to avoid a COVID-19 outbreak with potential spreading to many countries through returning pilgrims, Saudi Arabia suspended the Umrah, and access to the 2020 Hajj was very limited.

Summary

A clear relation between early suspension of religious mass gatherings and lower occurrence of COVID-19 transmission in countries that took such measures promptly was noticed. There are lessons to national and international health organizations for other mass gatherings in the context of the pandemic.

The Tokyo Olympic Games and the Risk of COVID-19

Purpose of Review

We reviewed the occurrence of outbreaks at past Olympics and discuss the threat of the COVID-19 pandemic at the Tokyo Games.

Recent Findings

Evidence for large respiratory tract infection outbreaks at past Olympics is scant. Nevertheless, in order to control the spread of the COVID-19 outbreak, the Tokyo 2020 Olympics were postponed for 2021. Given the high contagiousness of the disease and the epidemiology of COVID-19 in Japan, this decision was appropriate and important in order to safeguard athletes and the public. However, it is a major problem for Japan, involving massive financial losses and a lost opportunity for athletes, coaches, and instructors.

Summary

Up-to-date epidemiological data is needed on which to base an appropriate decision regarding the Tokyo 2021 Olympics. The actual effect of cancellations of such events in reducing the spread of COVID-19 needs to be determined.

Dynamics and genetic diversity of Haemophilus influenzae carriage among French pilgrims during the 2018 Hajj: A prospective cohort survey

BACKGROUND

To investigate the genetic diversity of Haemophilus influenzae positive samples among French pilgrims attending the 2018 Hajj pilgrimage.

METHOD

After screening by qPCR, multilocus sequence typing was performed for all H. influenzae-positive samples. The following housekeeping genes were amplified and assigned: adk, atpG, frdB, fucK, mdh, pgi and recA.

RESULTS

121 pilgrims were included. H. influenzae was positive in 35.5% pre-Hajj samples, 12.4% at day five post-arrival, 15.7% at day 12 post-arrival, and 43.0% post-Hajj. Of the 129 positive swabs for H. influenzae, only one sample at D12 was negative for all seven genes amplified by standard PCR. The adk, atpG, frdB, mdh, pgi, recA and fucK genes were positive in 123, 107, 122, 70, 127, 118 and 69 samples, respectively. One sequence of atpG and two of recA genes were not possible to assign. None of the sequences of fucK gene was successfully obtained. Consequently, a complete sequence type characterisation was not possible. Of the 128 obtained strains, 111 had distinct patterns of alleles.

CONCLUSION

H. influenzae genotypes acquired were completely different from those present at pre-Hajj. We observed a great biodiversity and a lack of clonality of H. influenzae among French pilgrims during the 2018 Hajj. Further studies aiming at studying the genome of Hajj-acquired H. influenzae isolates are needed to define the clinical burden of H. influenzae infection during Hajj and to evaluate the potential interest of vaccination in Hajj pilgrims.

Gastrointestinal symptoms and the acquisition of enteric pathogens in Hajj pilgrims: a 3-year prospective cohort study

The acquisition of enteric pathogens and risk factors for Hajj-associated diarrhea in Hajj pilgrims is poorly documented. Pilgrims from Marseille participating in the Hajj in 2016-2018 underwent successive systematic rectal swabbing before and after their travel. Carriage of the main enteric pathogens was assessed by real-time PCR. Baseline demographics, adherence to individual preventive measures, gastrointestinal symptoms, and treatments were recorded. A total of 376 pilgrims were included. The median age was 62.0 years. During the Hajj, 18.6% presented at least one gastrointestinal symptom, 13.8% had diarrhea, and 36.4% had acquired at least one enteric pathogen. Enteropathogenic Escherichia coli (EPEC) and Enteroaggregative E. coli (EAEC) were the pathogens most frequently acquired by pilgrims (17.6% and 14.4%, respectively). Being female was associated with increased frequency of gastrointestinal symptoms during the pilgrimage (aOR = 2.38, p = 0.004). Enterohemorrhagic Escherichia coli (EHEC) acquisition was associated with a four-fold higher risk of reporting at least one gastrointestinal symptom and diarrhea (aOR = 3.68 and p = 0.01 and aOR = 3.96 and p = 0.01, respectively). Pilgrims who suffered from diarrhea were more likely to wash their hands more often (aOR = 2.07, p = 0.03) and to be either overweight (aOR = 2.71, p = 0.03) or obese (aOR = 2.51, p = 0.05). Enteric bacteria such as E. coli that are frequently associated with traveler's diarrhea due to the consumption of contaminated food and drink were frequently found in pilgrims. Respecting strict measures regarding food and water quality during the Hajj and adherence to preventive measures such as good personal hygiene and environmental management will help reduce the burden of gastrointestinal infections at the event.

Risk factors for symptoms of infection and microbial carriage among French medical students abroad

Objectives

To investigate symptoms of infections and their risk factors among French medical students undertaking an internship abroad.

Methods

Clinical follow up, and qPCR-based respiratory, gastrointestinal, and vaginal pathogen carriages were prospectively assessed pre-travel and post-travel, in a cohort of medical students departing from Marseille, France.

Results

293 students were included. 63.5%, 35.8%, and 3.6% of students reported gastrointestinal, respiratory, and vaginal symptoms, respectively. The acquisition rate of Enteroaggregative Escherichia coli and Enteropathogenic E. coli was 40.9% and 18.6%, respectively. A significant increase was observed for rhinovirus and Streptococcus pneumoniae by comparing the prevalence of pathogens in pre-travel and post-travel samples. Gardnerella vaginalis and Atopobium vaginae acquisition rates were 12.9% and 13.9%, respectively. Being female, primarily traveling to Vietnam, and living in basic accommodation conditions were independent risk factors for reporting respiratory symptoms. Students reporting respiratory symptoms were three times more likely to acquire S. pneumoniae. Traveling primarily to north India and Senegal were independent risk factors for diarrhea.

Conclusion

This study makes it possible to identify the leading infectious diseases linked to travel in a group of French medical students undertaking an internship abroad and the risk factors on which to base targeting students for reinforced pre-travel advice.

Clusters of COVID-19 associated with Purim celebration in the Jewish community in Marseille, France, March 2020

OBJECTIVES

We investigated possible COVID-19 epidemic clusters and their common sources of exposure that led to a sudden increase in the incidence of COVID-19 in the Jewish community of Marseille between March 15 and March 20, 2020.

METHODS

All data were generated as part of routine work at Marseille university hospitals. Biological diagnoses were made by RT-PCR testing. A telephone survey of families in which a laboratory confirmed case was diagnosed was conducted to determine possible exposure events.

RESULTS

As of March 30, 2020, 63 patients were linked to 6 epidemic clusters. The 6 clusters were linked to religious and social activities: a ski trip, organized meals for the Purim Jewish celebration in community and family settings on March 10, a religious service and a charity gala. Notably, 40% of the patients were infected by index patients during the presymptomatic period, which was 2.5 days before symptom onset. When considering household members, all 12 patients who tested negative and who did not develop any relevant clinical symptoms compatible with COVID-19 were 1-16 years of age. The clinical attack rate (symptoms compatible with COVID-19, and biologically confirmed by PCR) in adults was 85% compared to 26% in children.

CONCLUSIONS

Family and community gatherings for the Purim Jewish celebration probably accelerated the spread of COVID-19 in the Marseille Jewish community, leading to multiple epidemic clusters. This investigation of family clusters suggested that all close contacts of patients with confirmed COVID-19 who were not infected were children.

Senegal's Grand Magal of Touba: Syndromic Surveillance during the 2016 Mass Gathering

The Grand Magal of Touba (GMT) is an annual 1-day Muslim religious event that takes place in Touba in Senegal. The city of Touba swells from 800,000 to four million people during the GMT. All patients who attended one of the 154 dedicated medical care public healthcare structures of the medical region of Diourbel during the GMT were included in a cross-sectional survey from November 16 to November 21, 2016. Demographic, morbidity, and mortality data were collected on a daily basis using a standardized article form that allows data to be recorded in a free-text format. Data were obtained from a total of 20,850 healthcare encounters, and 30.9% patients were aged ≤ 15 years. The most frequent conditions were gastrointestinal and respiratory diseases. Most frequent gastrointestinal symptoms were abdominal and gastric pain, nausea and vomiting, and diarrhea, suggesting that most patients suffered gastroenteritis. The predominance of cough, rhinitis, influenza-like illness, and sore throat among patients with respiratory symptoms suggests that most patients suffered from upper respiratory tract infections. Other frequent symptoms were headaches and pain in various organs. Three percentage of patients were considered to have malaria, 29.8% of patients were prescribed antibiotics and 2.6% antimalarial drugs, and 1.5% of patients were hospitalized. Only one death was recorded. Preparedness of the medical infrastructure should target these syndromic features, in terms of diagnostic tools and specific treatments, including pediatric formulations. It is also essential to improve the quality and rapid availability of data to enable real-time analysis of medical events at the GMT and to implement a rapid response, if necessary.

Pilot Survey of Knowledge, Attitudes and Perceptions of Hajj Deployed Health Care Workers on Antibiotics and Antibiotic Prescriptions for Upper Respiratory Tract Infections: Results from Two Hajj Seasons

Antimicrobial resistance (AMR) is a global public health issue. Upper respiratory tract infections (URTIs) are common illnesses during Hajj, for which antibiotics are often inappropriately prescribed. Hajj healthcare workers' (HCW) knowledge, attitudes and perceptions (KAP) about AMR and antibiotic use for URTIs are not known. We conducted a survey among HCWs during Hajj to explore their KAP regarding antibiotic use for URTIs in pilgrims. Electronic or paper-based surveys were distributed to HCWs during the Hajj in 2016 and 2017. A total of 85 respondents aged 25 to 63 (median 40) years completed the surveys. Most participants were male (78.8%) and were physicians by profession (95.3%). Around 85% and 19% of respondents claimed to have heard about AMR and antimicrobial stewardship programs, respectively, among whom most had obtained their knowledge during their qualification. Implementation of URTI treatment guidelines was very low. In conclusion, HCWs at Hajj have significant knowledge gaps regarding AMR, often do not use standard clinical criteria to diagnose URTIs and display a tendency to prescribe antibiotics for URTIs.

Infectious disease symptoms and microbial carriage among French medical students travelling abroad: A prospective study

Background

In France, no previous studies have focused specifically on health problems among medical students during internships abroad including the clinical symptoms suggestive of infectious diseases and the acquisition of pathogen carriage.

Methods

Clinical follow up and qPCR based respiratory, gastrointestinal and vaginal pathogen carriage before and after travel were prospectively assessed in a cohort of medical students departing from Marseille, France.

Results

134 students were included. 73.9%, 38.8% and 5.0% of students reported gastrointestinal, respiratory and vaginal symptoms, respectively. The acquisition rate of Enteroaggregative Escherichia coli (EAEC) and Enteropathogenic E. coli (EPEC) was 53% and 41%, respectively. The acquisition of respiratory viruses was low but associated with persisting symptoms, while bacterial acquisition ranged from 3.3% for Streptococcus pyogenes to 15.0% for Haemophilus influenzae. Gardnerella vaginalis and Atopobium vaginae acquisition rates were 7.7% and 14.3% respectively. Five students (5.1%) had molecular quantification criteria for bacterial vaginosis on return.

Conclusion

This preliminary study demonstrates that besides the known risk of gastrointestinal and respiratory infections and associated changes in intestinal and respiratory microbiota, medical students abroad may also experience changes in vaginal microbiota leading, in some cases, to clinical symptoms or the acquisition of bacterial vaginosis, which may be asymptomatic.